SESSION TITLE: Cardiovascular Cases I
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Sunday, October 27, 2013 at 07:30 AM - 08:30 AM
INTRODUCTION: Development of accessory veins is common cause for failure of maturation of arterio-venous (AV) fistula created for hemodialysis. Coil embolization of accessory vein is an available treatment option. We report an extremely rare case of migration of coil from AV fistula to right ventricle, which latter migrated to right pulmonary vasculature.
CASE PRESENTATION: A 65 year old male came to hospital for evaluation of non-maturing left upper limb AV fistula created for hemodialysis. His past medical history was significant for diabetes mellitus, hypertension, end-stage renal disease and diastolic heart failure. Fistulogram showed modest stenosis in the mid fistula with two (superior and medial) large accessory veins. Superior accessory vein measuring 4 mm was embolized with two 8 mm coils and 6 mm medial accessory vein was embolized with two 10 mm coils. While performing angioplasty for the stenosis, it was noted that both coils from the medial accessory vein had migrated. Chest X-ray (CXR) (Figure 1) showed both coils in right ventricle. Multiple unsuccessful attempts were made to retrieve coils from right ventricle using an endovascular snare under fluoroscopy. Next day, CXR (figure 2) showed further migration of the coils to the right lung. Repeated attempts to retrieve coil from the right pulmonary vasculature were unsuccessful. Patient remained asymptomatic throughout the course of hospitalization and his vitals were stable with oxygen saturation of 97%. He was discharged to follow up with pulmonologist.
DISCUSSION: Migration of coil to heart and lung is a very rare phenomenon1. High flow fistula and inappropriate size are common risk factors for migration of coil. Right atrium and ventricular tricuspid annulus are common sites for migration but smaller coils can migrate to pulmonary vasculature1. Coils left in right ventricle and lungs are generally asymptomatic but can present with hemoptysis, chest pain, arrhythmia and dyspnea. Cardiothoracic surgery is indicated in symptomatic patients. Endovascular or percutaneous retrieval of coils can be attempted in stable patient. Long term anticoagulation is not indicated for unsuccessful retrieval of coil from lung or heart.
CONCLUSIONS: Migration of coil to lung and heart is an extremely rare complication of coil embolization. It can be life threatening but coils can be left in situ in most cases without any significant implications.
Reference #1: Prokesch RW, Bankier AA, Ba-Ssalamah A, Schima W, Bader TR, Lammer J. Displacement of coils into the lung during embolotherapy: clinical importance and follow-up with helical CT. Acad Radiol. 2001;8(6):501-8.
DISCLOSURE: The following authors have nothing to disclose: Anup Singh, Charu Ramchandani, Krishna Tangirala, Farhad Nasar, Keith Schroeder, Roy Trumbo
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